LOW BACK PAIN

Dr. Dileep Kumar

MS (Ortho)
Assistant Professor
 INTRODUCTION
• Low back pain is a very common problem and has
a ubiquitous distribution.

• The most common cause of LBP is lumber disc

disease.

• Bad posture plays a very significant role in the

genesis of LBP.

• LBP refers to pain from the low lumber areas,

lumbosacral areas and both the sacroileac joint.
• Low back pain is an extremely common
malady affecting the human race across globe.

• It is a price mankind has to pay for their

upright posture
 Epidemiology
• 60 – 90% of adults experience back pain at some point in their
life.
-  incidence age 35- 55 yr.
- 90% resolve in 6 weeks.

- 7% become chronic.
- M/F equally affected.

• 5th Leading reason for medical visits.

 Normal posture of spine
• Moderate lordosis of
cervical and lumber spine.

• Kyphosis of the thorasic

and sacrococcygeal section.

• Forward pelvic inclination

of 30 degree.

• Neutral rotation og femur.

 Pathophysiology
• Physiologic curves give the spine its “S” shape.

• If due to our posture this “S” curve fails to

maintain, muscles attach to spine starts to ratain
posture by contraction.

• Repeated contraction of muscle causes fatigue

and strain in ligaments and posterior articulating
faces and pain starts over back.
 Common causes of backache
• Unaccustomed activities
• Poor posture
• Occupational backache
• Obesity
• Muscle strain
• Prolapsed lumbar intervertebral disc
• The facet joint arthritis
• Spinal stenosis
• Osteoporosis/Osteomalacia
 Uncommon causes of backache
• Spina bifida
• Lumber scoliosis
• Tuberculosis
• Ankylosing spondylitis
• Neoplastic diseases affecting spine
• Pain referred from viscera
• Spondylolysis
• Spondylolisthesis
 Structures Involved in Backache
• Vertebral bodies

• Intervertebral disc

• Posterior intervertebral joint

• Ligaments and small intervertebral muscles

• Posterior longitudinal ligament

• Nerves
Common Pathoanatomical Conditions of the Lumbar Spine
 Disc Herniation – Physiology
• Tears in the annulus.

• Herniation of nucleus
pulposus.
 Disc Herniation – Physiology
• Compression of the
nerve root in the
foramen leads to pain.

• Lumber disc prolapse

most commonly occurs
in L4-5 vertebral level.
 Level of disc prolapse and nerve root
compression
Disc Pain Radiation Sensory Motor loss
prolapse loss
between
L3 and L4 Lumber Along the Medial Quadriceps Knee jerk- Normal
(L4 nerve region antero- shin
root medial
involve) aspect of
thigh
L4 and L5 Lumber Lateral 1st toe area Extensor Medial Redused
(L5 nerve region, thigh, leg, hallucis hamstrings
root is groin, dorsum of muscle
involve) Sacroiliac the foot
region and 1st toe
L5 and S1 Lumber Buttocks, Lateral foot Grastrocne Ankle jerk Reduced
region, posterior -mius
groin, thigh,leg
Sacroiliac and lateral
region foot
 Easy way to remember
• L4 nerve root involvement-
“4” heads of Quadriceps.
Hence knee jerk affected.

• L5 nerve root involvement-

“5” toes- Great toe and
lateral 4 toes lose extension.

• S1 nerve root involvement-

“A” of Tendo-Achilles.
Hence, ankle jerk lost.
 Disc Degeneration – Physiology
• With age and
repeated efforts, the
lower lumbar discs
lose their height and
water content (“bone
on bone”)

• Abnormal motion
between the bones
leads to pain.
 FEATURES OF PAIN
• LOCATION - The pain may be located in the
lower middle or upper back .

• Disc prolapse and degenerative spondylitis

occur in the lower lumbar spine.

• Infection and trauma occur in the dorso lumbar

spine.
• ONSET- Often there is a history of significant
trauma immediately preceding the onset of the
back pain.

• LOCALISATION OF THE PAIN- A pain

arising from the tendon or muscle injury is
localized whereas that originating from the
deeper structures is diffuse.
• PROGRESS OF PAIN
• In traumatic and in acute disc prolapse the pain is
maximum at onset and then gradually subsides.

• The back pain due to disc prolapse often has

periods of remission and exacerbations, an
arthritic pain is more constant.
 RELIEVING OR AGGRAVATING
FACTORS
• Most back pains are worsened by activity and relieved by
taking rest.

• Pain due to ankylosing spondylitis and sero negative

arthritis are typically worse after taking rest, and improve
with activity.

• A pain initiated on walking or standing and relieved by

rest is a feature of spinal stenosis.

• An increase in pain during menstrual period indicates

gynaecological pathology.
• SPASM-Muscle spasm may be present in acute back pain
and can be assess by the prominence of the para vertebral
muscles at rest which stand out on the slightest movement.

• TENDERNESS-Localized tenderness may be indicate a

ligament or muscle tear.
• Pain originating from the sacro iliac joint may have
tenderness localized to the posterior superior iliac spine.

• SWELLING-A cold abscess may be present, indicating

tuberculosis as the cause.
 Assosiated symptoms
• STIFFNESS- Associated with most painful
backs but it is a prominent symptom in pain due
to ankylosing spondylitis, more in early morning.

• PAIN IN OTHER JOINTS- In Rheumatic

diseases.

• RADICULOPATHY- Pain in distribution of the

sciatic nerve. Generally occurs due to disk
herniation.
• Also called as Sciatica.
• EXTRA SKELETAL SYMPTOMS- A history
suggestive of abdominal complaints, urogenital
complaints or gynecological complaints may
indicate an extra skeletal cause of pain.

• THE PSYCHOLOGICAL STATUS- of the

patient must be judged to rule out hysteria or
malingering as a cause of back pain.
 Physical examination
• 1) STANDING POSITION

• POSITION
• Normally a person stands erect with the center of the
occiput in the line with the two shoulders are at the same
level, the lumbar hollows are symmetrical and the pelvis
is square.

• In case of back pain look for scoliosis, kyphosis, lordosis,

pelvic tilt, and forward flexion of the lower limbs.
 Range of movement

• Flexion- 80 degree

• Lateral flexion-35 degree

• Extension-20-30 degree

• Rotation- 45 degree
 2) Lying down position

• Straight leg raising test

• Peripheral pulses

• Adjacent joints

• An abdominal rectal or per vaginal

examination
 STRAIGHT LEG
STRAIGHT LEG RAISE
RAISETEST
TEST
The straight leg raise
test is positive if pain
in the sciatic
distribution is
reproduced between
30° and 70° passive
flexion of the straight
leg. Dorsiflexion of the
foot exacerbates the
pain.
 Modifications of SLRT
• Lasegue’s test

• Buckling’s sign

• Sicard’s test

• Fajersztajn’s test
Lumbrosacral Dermatones
 INVESTIGATIONS
• The diagnosis of back pain is essentially
clinical.
• There is no use of getting x-rays done in acute
back pain less than 3 weeks duration.

• There are number of other investigations like

CT scan, MRI, bone scan, blood investigations
etc.
 BLOOD INVESTIGATIONS
• These should be carried out in case if one
suspects malignancy, metabolic disorders, or
chronic infections.
 RADIOLOGICAL EXAMINATION

• Routine x rays of the lumbo-sacral spine and

pelvis should be done in all cases.

• Though x-rays are usually normal in non

specific back pain these provide a base line.

• It shows bony pathology.

Abdomen, X-ray, Anteroposterior View
1. 1st Lumbar vertebra
2. 2nd Lumbar vertebra
3. 3rd Lumbar vertebra
4. 4th Lumbar vertebra
5. 5th Lumbar vertebra
6. T12
7. Twelfth rib
8. Sacroiliac joint
9. Sacrum
10. Sacral foramen
11. Ilium
12. Pelvic brim
13.Superior ramus of
pubic bone
14. Pubic symphysis
 MRI/CT
MRI-To rule out soft tissue pathology or nerve
root compression.

CT- To rule out mainly bony pathology.

• Bone scan- It may be helpful if a benign or
malignant bone tumor is suspected on clinical
examination but is not seen on plain x rays.

• Electromyography- To rule out nerve root

compression.

• Discography
 TREATMENT
• Conditions for treatment- An unremitting backache not
cured by simple treatment methods.

• A backache with pain radiation to legs.

• Sensory compromise.

• Bladder and bowel disturbances.

• Severe backache and severe restrictions of spine.

• Backache due to spine deformities, infections, trauma,

ankylosing spondylitis, rheumatoid diseases , malignancy etc.
• Most back pain fall in non specific category
have a set of program of treatment mostly
conservative.

• It consists of rest, drug, hot packs, spinal

exercises, traction corset, education regarding
prevention of back pain etc.
 DRUGS
• Drugs like pain killers, muscle relaxants, anti
depressants, calcium supplements, vitamin
supplements and very rarely steroids.

• Local application of the ointment and gel are

also widely recommended.

• Drugs are however not safe for long periods.

 PHYSIOTHERAPY
• This is an important method of treatment and
may be used to support the drug treatment or
during post surgical recovery.

• There are various recommended physiotherapy

methods of treatment.
 HEAT THERAPY
• Heat helps to increase the blood circulation to
the skin muscles, bones and joints.

• Increased blood supply takes away the pain

producing sustains from the tissues and rids
patient of the pain.

• E.g. hot water packs and infrared rays.

 COLD THERAPY
• It consists of ice packs, ice massage, cold
water packs etc.

• It is very effective if used within 24 hrs. of an

acute injury of the back.

• After 24-48 hrs. one can switch over to heat

therapy
 MASSAGE
• This has been a very common method of
treatment since ages.

• It is a popular method and if done skillfully it

provides a soothing effect and induces
relaxation of spine muscles and ligaments.
 Pelvic traction
• This method involves applying pulling forces
over the muscles, ligaments and joints with the
help of appropriate pulling devices.

• This induces relaxation of the muscles and

ligaments, separates the bones and joints and thus
helps to reduce pain and muscle spasm.

• It ensures complete bed rest too.

 ADJUVANT METHODS
• LUMBO SACRAL CORSETS

• They are useful in acute stages of low back pain

and also act as a psychological boost.

• However it weakens the spine if used for prolong

period as the back muscles tend to get weakened
due to inactivity.

• It negates the advantages gained by the way of

exercises which actually strengthens back muscles.
 EXERCISES OF THE BACK
• Exercises serve the role of putting spine back
to its normal shape.

• They are aimed to strengthen posterior spinal

muscles, abdominal muscles and thigh
(quadriceps) muscles.

• To tone the other muscles of the trunk.

 GENERAL INSTRUCTIONS
• Do exercises on a hard floor
• Do all exercises at least five repetition each
time slowly increase it to ten
• Be well relaxed and at ease
• Use well fitting clothes
• Keep breathing rhythmically
• If it increase pain abandon it
• If possible do exercises in company.
 EXERCISES RECOMMENDED FOR
BACK
• ABDOMINAL MUSCLE EXERCISES

1. Head raising exercises

2. Straight leg raising exercises
3. Knees to chest exercises
4. Abdominal flexion to toe touch
5. Rotational exercises
Exercises of trunk hip and thigh muscles

1) Hip extension
2) Trunk flexion
3) Quadriceps exercises
4) Hamstring stretch exercises
5) Back extensor muscles exercises
PREVENTION OF BACKACHE
 Surgery
• Laminectomy and disc excision

• Hemileminectomy

• Fenestration surgery

• Microscopic and Endoscopic lumbar

discectomy
 Newer procedures
• MISS (Minimally invasive spinal surgery)

• Laser diskectomy

• Percutaneous diskectomy

• Total disc replacement

THANK YOU
MCQ
 MCQ-1
• The most common cause of LBP is-

A. Metabolic
B. Malignancy

C. Trauma
D. Lumber disc disease
 MCQ-2
• Structure not involved in Backache-

A. Intervertebral disc

B. Posterior intervertebral joint

C. Anterior longitudinal ligament

D. Posterior longitudinal ligament

 MCQ-3
• A back pain initiated on walking or standing and relieved by
rest is a feature of-

A. Spinal stenosis

B. Osteoporosis/osteomalacia

C. Ankylosing spondylitis

D. Tuberculosis
 MCQ-4
• The straight leg raise test is positive-

A. Between 30° and 70° passive extention of the straight leg.

B. Between 30° and 70° passive flexion of the straight leg.

C. Between 30° and 70° active flexion of the straight leg.

D. Between 30° and 70° active extention of the straight leg.

 MCQ-5
• Lumber disc prolapse most commonly occurs in-

A. L3-4 vertebral level

B. L4-5 vertebral level

C. L2-3 vertebral level

D. L1-2 vertebral level

 ANSWERS
• 1) D
• 2) C
• 3) A
• 4) B
• 5) B